OpenSig 2003 Registration Form

First Name: _____________________ Last Name: ______________________
Affliation: ______________________ Email: __________________________
Street Address: Telephone: _______________________
___________________________ FAX: ___________________________
___________________________ Name on Badge: __________________
City: ___________________________ State/Provence: ____________________
Zip/Postal Code: ____________ Country: __________

Dietary Restrictions:        Vegetarian Other (specify): ________________

Credit Card (please check one):
_____ Visa
_____ MasterCard
Credit card number: ____________________________________
Expiration Date: ____________________________________
Name as it appears on the credit card: ____________________________________
Total Charges Authorized: $190.00 ($220.00 if received after Sept 25)
Signature: ____________________________________
Do you need a hard copy receipt? [  ] YES

[  ] NO

Please note that by signing above, your credit card will be charged $190.00 (or $220.00 if received after September 25th).


For further information please contact the workshop chairs.